Wei Han Ong¹

¹ Foundation Doctor, Ninewells Hospital, NHS Tayside, Dundee, United Kingdom

I would like to challenge those reading this to take a moment to think about how different life has been since the first quarter of 2020 gave light to a novel virus, Coronavirus 2019 (COVID-19), causing a pandemic of unbridled proportions. Hindsight is a cruel judge. When reflecting on this global pandemic, a singular emphasis on COVID-19 death rates provides an incomplete picture of health and wellbeing this disease will have on the population. As future health care professionals, it is crucial for us to scrutinise the bigger picture of how undersupply of care due to cutbacks in routine health services may lead to an increase in morbidities and mortalities outside a pandemic.

This is particularly evident in ophthalmology considering it represents one of the busiest and most heavily outpatient-oriented specialties, with approximately 7.5 million outpatient appointments and over 500,000 surgical procedures being provided in the United Kingdom each year (1). While serious eye conditions remained prioritised, many patients were too fearful to attend essential clinic appointments. Statistics showed that there was a 79% reduction in ophthalmic appointments in the UK (the highest of any medical specialty) during the pandemic (2). It is estimated that more than three thousand people have lost vision due to delays in the identification and treatment of eye disease during the pandemic (2). The pandemic crisis will end, sooner or later but the real challenge remains: the episodes of avoidable sight loss that may have occurred due to backlog of services.

Therefore, if there ever was a time for ingenuity and unrealistic ambition, perhaps it should be in the next few years as these unprecedented times required effective reformation and novel adaptations to maintain sight-saving care provision.

Tele-ophthalmology: Need of the hour

So, how shall we build an improve capacity for ophthalmic services? I hear you ask. I believe the concept of teleophthalmology can be the solution to all our burning questions. Providing healthcare from a distance, telemedicine is a growing branch of medicine in recent years and while it has been long in existence prior to the pandemic, the COVID-19 situation boosted the demand in this service.

After all, image-based investigations are the crux of diagnosing ophthalmic condition and teleophthalmology offers the benefits of using smartphones, advanced software or remote video tools to deliver high quality images while eliminating distances, reducing waiting times and avoiding unnecessary patient contact.

An article by Nikolaidou and Tsaousis perfectly encapsulated the principle of embracing teleophthalmology and artificial intelligence as game changers in ophthalmic care post pandemic (3). Do we always need to see each patient in person? As a progressive specialty, we have to be quick to take advantage of the new technology in ophthalmology. Virtual clinics may just hold the answer to provide a promising solution to ensure that patients are seen and treated in a timely fashion.

What then, of the patients who do need to be seen and treated in an Eye Clinic. Going forward, the elephant in the room when it comes to future healthcare is certainly Artificial Intelligence (AI). Breakthroughs in deep-learning algorithms in the management of medical retina conditions appear promising. Patient self-screening, which has been shown to be effective using the near card and Alleye program, may help optimize prioritization protocols for clinic visit and intravitreal injections (4). Moreover, AI technologies can be used as tele-screening tool to capture fundus photography to screen and diagnose age-related macular degeneration (AMD) or diabetic retinopathy (DR) with high specificity and sensitivity (4). Nevertheless, only few of these novel screening technologies are currently commercially available due to uncertainties around relevant cost and clinical evidence. Therefore, it is of high time for research to address potential challenges, including medicolegal implications, ethics, and clinical deployment model in order to expedite the translation of these novel technologies into the healthcare setting.

Community partnership

In view of the fact that existing approaches to monitor chronic conditions such as AMD and DR, which are not often immediately life or sight threatening, have been abandoned because of the priority to preserve life during the pandemic, I would like to outline how the future delivery of ongoing care in the community can be redefined by the pandemic.

Ultimately, the goal of future healthcare should be this; a shift in emphasis from placing the burden of patient management from Secondary/Tertiary Care towards Primary Care, where possible. Patients may not even have to see an ophthalmologist to present their symptoms, have relevant investigations and be started on appropriate treatment. The pandemic has just highlighted reliance upon community partners, particularly optometrists. Optometrist-led community hubs such as the COVID-19 Urgent Eyecare Service (CUES) and Emergency Eye Treatment Centres (EETC) were central to the provision of acute eye care without the need for hospital attendance.

In conjunction with the launching of the new smart phone assisted slit-lamps, tele-examination of an eye is no longer a fantasy as this device utilises 4k real time streaming to provide a high quality video feed where the smallest details of disease can be visualised by an ophthalmologist who may be many miles away (5). This way, most patients can be triaged remotely, reducing unnecessary and costly hospital visits, and optimizing access to medical care. It also enables referrals to be made by remote verification of the imaging performed close to the patient (for example, at the local optician or optometrist) by hospital-based experts. A video consultation platform “Attend Anywhere” in Moorfields Eye Hospital’s accident and ED (London, UK) had thriving results for patient satisfaction, consultation duration and waiting time. This accoladed video A&E service, used in over ¼ of appointments, has reduced hospital attendance by over 80% (6).

Reshaping ophthalmology training- Jack of all trades or Master of (more than) one?

There are growing calls for return of the general ophthalmologist, amplified by the hurdles that we continue to face years into a pandemic. Rather than addressing a single ailment during a visit, managing a second condition where possible would go a long way to reducing additional clinical appointments and leading to happier patients. Truth is, patients do no identify with the ‘retina clinic’ or the ‘cornea clinic’. They simply attend the ‘eye clinic’, in hope that their needs can be all addressed in a single setting.

Undeniably, some patients will indeed require expert specialist care for which there can be no substitute. But on a whole, it is not farfetched to claim that a notable proportion of patients can be managed safely in a general ophthalmology clinic. Sub-specialisation has been the ultimate long-term goal of many ophthalmology trainees or consultants in recent years. But maybe, it is time for us to ponder whether we should take a step back into the past when an ophthalmology consultant was expected to be the ultimate multi-specialist!

Conclusion

This somewhat surprising pause in service has given us the perfect opportunity to adapt and discover ways of running the ophthalmology service more efficiently by harnessing new ways of working, including the streamlining of services, reduction of backlog and the incorporation of telemedicine. Although a large number of concepts were proposed and, in some cases, already implemented before the pandemic, digital health approaches, such as telemedicine, virtual clinics and home monitoring, were a shadowy existence in the care landscape. As the lockdown is eased and ophthalmology services are gradually reinstated to their pre‐pandemic status, the challenge will be to examine which of these novel ways of working are here to stay. How do we continue to protect our patients, minimise the risk of virus transmission and ensure that we deliver much‐needed treatment in a timely manner?

Change is the only certainty when it comes to predicting the future, but in whatever way healthcare changes, ophthalmic patients should rest assured: Vision will always be profoundly cared for.

References

1. ‘Getting it right first time’ in ophthalmic surgery [Internet]. UK and International Law Firm. [cited 2023May5]. Available from: https://www.penningtonslaw.com/news-publications/latest-news/2022/getting-it-right-first-time-in-ophthalmic-surgery
2. Young K. Report describes the cost of the pandemic on Eye Health [Internet]. Association of Optometrists (AOP) – Homepage. [cited 2023May5]. Available from: https://www.aop.org.uk/ot/science-and-vision/research/2021/09/17/report-describes-the-cost-of-the-pandemic-on-eye-health
3. Nikolaidou A, Tsaousis KT. Teleophthalmology and Artificial Intelligence as game changers in ophthalmic care after the COVID-19 pandemic [Internet]. Cureus. 2021 [cited 2022Jun4]. Available from: https://www.cureus.com/articles/63413-teleophthalmology-and-artificial-intelligence-as-game-changers-in-ophthalmic-care-after-the-covid-19-pandemic
4. Ahmed I, Liu TYA. The impact of covid-19 on diabetic retinopathy monitoring and treatment – current diabetes reports [Internet]. SpringerLink. Springer US; 2021 [cited 2022Jun4]. Available from: https://link.springer.com/article/10.1007/s11892-021-01411-6
5. Communications NHSFV. World’s first 5G tele-examination of an Eye [Internet]. NHS Forth Valley. 2019 [cited 2022Jun4]. Available from: https://nhsforthvalley.com/worlds-first-5g-tele-examination-of-an-eye/
6. Kilduff CLS, Thomas AAP, Dugdill J, Casswell EJ, Dabrowski M, Lovegrove C, et al. Creating the moorfields’ virtual eye casualty: Video consultations to provide emergency teleophthalmology care during and beyond the COVID-19 pandemic [Internet]. BMJ Health & Care Informatics. BMJ Publishing Group Ltd; 2020 [cited 2022Jun4]. Available from: https://informatics.bmj.com/content/27/3/e100179